History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1935 Vancouver Medical Association Jan 31, 1935

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 I'M
The BULLETIN
OF THE
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VANCOUVER MEDICAL
I    ASSOCIATION*
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Vol. XI
JANUARY, 1935
No. 4
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In This Issue:
NEWS AND NOTES
FOCAL INFECTION    ::   TUMOURS OF THE BREAST
WILLIAM OSLER  THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Published ^Monthly under the ^Auspices of the Vancouver iftledical ^Association in the
Interests of the ^Medical "Profession.
Offices:
203 Medical Dental Building, Georgia-Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Batrd Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI JANUARY, 193 5 No. 4
OFFICERS   1934-193 5
Dr. A. C. Frost Dr. C. H. Vrooman Dr. W. L. Pedlow
President Vice-President Past President
Dr. W. T. Ewing Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive:—Dr. H. H. McIntosh, Dr. L. H. Appleby
TRUSTEES
Dr. W. D. Brydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. W. L. Graham         Chairman
Dr. J. R. Neilson    -  Secretary
Eye, Ear, Nose and Throat
Dr. E. E. Day   —    Chairman
Dr. H. R. Mustard    Secretary
Paediatric Section
Dr. G. A. Lamont     Chairman
Dr. J. R. Davies         ..Secretary
Cancer Section
Dr. A. B. Schinbein — —      Chairman
Dr. J. W. Thomson   Secretary
STANDING COMMITTEES
Library Summer School
Dr. W. D. Keith Publications Dr. H. A. DesBrisay
Dr. C H. Bastin Dr      h MacDermot Dr. H. R. Mustard
Dr. A. W. Bagnall Dr Jd e r Cleveland Dr. J. W Thomson
Dr. G E Kidd Dr MuRRAy Baird Dr. C E. Brown
Dr. W. K. Burwell Dr. J. E. Walker
Dr. C A. Ryan Dr. J. W. Arbuckle
n. Credentials Hospitals
n     .J:'"1'6" Dr. R. A. Simpson Dr. T. H. Lennie
SR' I" Z; THOMSON Dr. J. T. Wall Dr q r Covernto>
n*' Ir r r™ Dr' D' M" MeekisoN Dr. H. H. Milburn
Dr.W.G.Gunn Dr.S.Paulin
V. O. N. Advisory Board
Dr. I. Day R°P- to B- c- Medical Assn.
Dr. H. H. Boucher Dr. Wallace Wilson
Dr. W. S. Baird
Sickness and Benevolent Fund — The President — The Trustees
V:
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Urn 1        Tuberculosis Spread ;,
Through Raw Milk
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pvOCTOR R. M. PRICE, Department of Pathol-
1-^ ogy and Bacteriology, University of Toronto,
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had to say in a recent article of his, published in the
III
Canadian Public Health Journal:
"In a study of three hundred tuberculous children in Toronto, it was
found   that   fifteen   per   cent   of   the   extra-pulmonary   tuberculosis   {e.g.,
bone, joint, lymph nodes, kidney and skin)  was due to the bovine type of
tubercle bacillus.
Iff!
"Infection with the bovine type occurred most- commonly in the region
of cervical lymph glands.
"All the cases of infection with the bovine type had used raw milk and
came from points outside of Toronto.   The clinical investigation indicated
the alimentary route of infection.
"The majority of children infected with the human type gave a history
of contact with  human  tuberculods.    The  clinical  investigation  indicated
the respiratory route of infection.
"Of two hundred  samples of  nnpoolcd raw milk examined, eight or
four per cent yielded tubercle bacilli on direct smear and guinea pig inoculation.
Pljjjfp
p  I'JIme
"Of  one   hundred   samples   of   pooled   raw   milk,   twenty-six   yielded
tubercle bacilli.
"Of one hundred samples of the same milk, pasteurized, none showed
tubercle bacilli on guinea pig inoculation.
"This finding is confirmed by the fact that not a single case of bovine
tuberculous infection has been encountered in this generation of children
raised on pasteurized milk in Toronto, where pasteurization is compulsory
and has been rigidly enforced since 1915."
C   'Ii t   '
1             ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
SERVICE phones:
Fairmont 1000     North 122     New Westminster 1445 VANCOUVER HEALTH DEPARTMENT
STATISTICS—NOVEMBER,  1934
Total Population (Estimated)    243 711
Japanese  Population   (Estimated)      7 866
Chinese Population  (Estimated)  8 315
Hindu Population  (Estimated)... 251
Rate per 1,000
Number Population
Total Deaths                                                                                       178 8.8
Japanese   Deaths                                                                                    7 10.8
Chinese Deaths                                                                                    11 16.1
Deaths—Residents  only                                                                         160 8.0
Birth Registrations:
Male, 134; Female, 142...                                                        276 13.8
INFANTILE MORTALITY— November, November,
1934 1933
Deaths under one year of age   4 10
Death rate—per  1,000 births... 14.5 39.5
Stillbirths (not included in above) ... 10 9
CASES  OF  COMMUNICABLE  DISEASES  REPORTED  IN  THE  CITY
October, November, December 1st
1934 1934 to 15th, 1934
Cases     Deaths        Cases     Deaths        Cases     Deaths
Smallpox —   0 0                  0 0 0 0
Scarlet   Fever  53 0 38 0 24 0
Diphtheria       0 0                  2 0 3 0
Chicken Pox  54 0 65 0 49 0
Measles     0 0                  0 0 0 0
Rubella    10                  0 0 0 0
Mumps      3 8 0 43 0 13 0
Whooping-Cough .. 20 0 24 0 7 0
Typhoid Fever  2* 0                  1* 0 1* 0
Undulant Fever... 0 0                  0 0 0 0
Poliomyelitis .... 0 0                   0 0 0 0
Tuberculosis  ..... 63 10 59 16 22
Meningitis   (Epidemic)... 0 0                  0 0 0 0
Erysipelas       2 0^00 20
Encephalitis Lethargica... 0 0                  0 0 0 0
Paratyphoid     0 0                  0 0 0 0
* Non-Resident.
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S. BOWELL & SON
DISTINCTIVE  FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
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Page 69 ' '.
PUBLIC HEALTH
BIOLOGICAL PRODUCTS
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■ in
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Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid   (Anatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum  (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratori
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
macdonald's Prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER MEDICAL ASSOCIATION
Founded   1898     ::    Incorporated   1906
Programme of the 3 7 th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on Agenda.
General meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of the evening.
1934.
October 2nd—GENERAL MEETING.
Dr. G. F. Amyot: "Infection, Its Spread and Control."
Discussion:  Dr. E. D. Carder
Dr. H. A. Spohn.
October 16th—CLINICAL MEETING.
November 6th—GENERAL MEETING.
Dr. C. E. Brown: "Some Secretory Disturbances of the Stomach."
Discussion: Dr. H. A. DesBrisay.
Dr. A. Y. McNair.
November 20th—CLINICAL MEETING.
December 4th—GENERAL MEETING.
Dr. A. B. Schinbein: "Tumours of the Breast."
Discussion: Dr. J. J. Mason
Dr. B. J. Harrison
Dr. H. H. Pitts.
December 18th—CLINICAL MEETING.
1935.
January 8 th—GENERAL MEETING.
Dr. W. E. Ainley: "The Relation of the Retina to Cardio-Vascular
and Renal Disease."
Discussion: Dr. W. D. Keith
Dr. Wallace Wilson.       (
January 22nd—CLINICAL MEETING.
February 5 th—GENERAL MEETING.
Dr. Murray Blair: "Physiological Observations in Obstetrics."
Discussion: Dr. W. S. Baird.
February 19th—CLINICAL MEETING.
March 5 th—GENERAL MEETING.
The Osler Lecture—Dr. Wallace Wilson.
March  19th—CLINICAL MEETING.
April 2nd—GENERAL MEETING.
Dr. F. W. Emmons: "The Surgery of the Presacral Nerve."
Discussion: Dr. J. J. Mason
Dr. F. Turnbull.
April  16th—CLINICAL MEETING.
April 23rd—ANNUAL MEETING.
Page 70
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the outstanding sedative ♦ ♦ ♦
Odourless, tasteless valerian and strontium bromide are the basis of
Elixir Bromo-Valerianate (Gabail). NO BARBITAL. Prescribe a teaspoonful t.i.d. for hysteria, neurasthenia and other nervous affections.
ELIXIR BROMO-VALERIANATE (Gabail)
Obtainable from B. C. DRUGS LIMITED, Vancouver
GEORGIA PHARMACY, Vancouver McGILL & ORME, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL EDITOR'S PAGE
At this time of year, it is our pleasant duty and privilege to wish all out
readers what are called the Compliments of the Season. Christmas is by
with, and the turkey and hot mince pie have ceased from troubling, and
the liver is at rest—but there is still time to wish for a Happy and Prosperous
New Year for everyone. After all, the depression has had some redeeming
features, though they take looking, for. It has taught us that we can live
on a lower scale than we had thought possible, and still be reasonably happy;
it has made it possible for us to admit to being "broke," without necessarily
admitting complete inferiority—indeed, it is getting so that Robert Burns'
immortal lines,
"Wha's he, for honest poverty
That hings his head, and a' that?
The gowd (but we're off the gowd standard, so that it is not
even) but the guinea's statup,
The man's the man for a' that"
are once more becoming recognised as the truth.
It has done other things. It has brought the day closer when the wealth
that medical science has to offer will be available to all who need it, anc
not only to those who can afford it, and when we may reasonably hope that
disease will be nipped in the bud rather than left to reach its fruition of
blight and corruption, when all too often all our efforts are useless or merely
palliative. We must all hope that this angle of disease prevention will be
the one heavily stressed in any measure that our legislators may in their
wisdom suggest.
It has brought humanity closer together. Never in the history of man
has there been as much honest effort toward peace on earth and goodwi
toward men, as we have seen of late. The millennium is probably a few
years away, even though our new mayor will doubtless do his best to hurry
it along—but it is still perceptibly closer; and it is not only poverty anc
fear of poison gas that are helping to avert the war that so constantly threatens, but the feeling, born of this terrible cloud of loss and destitution that
overhangs the whole world, that we must work, not towards the restoration
of the old order, with its selfishness and individualism and laissez faire attitude, but towards the establishment of a new order, where the "brotherhooc
of man," of which Tennyson speaks, will be the keynote, and not the
"rights" of man.
So the outlook is not by any means all dark. In fact, we may hope that
we are merely undergoing the pangs of a new birth: and birth is always a
painful proceeding. We have various able obstetrical specialists to help us
—the Telfords and McGeers and Douglases and Stevenses, and even the
Bennetts have been taking postgraduate courses and have obtained some
new ideas on the subject. So far they seem to have been using oxytocics
rather than making any attempt to obtain painless labour—but perhaps we
are prejudiced. Anyway, we must hope that they will soon agree on the
course to be followed, and give us a "happy issue out of all our afflictions."
The excellent example set by Dr. F. J. Nicholson, in his recent donation
of $2 50 to the Vancouver Medical Association, has set us thinking. Why
should not those of us who are likely to be able to leave considerable sums
of money behind them, when (absit omen!) they shuffle off this mortal coi .
bequeath some of their wealth to be used in research, and given to some of (^bttuanj
I',
The death of Dr. James L. Turnbull on Christmas
Day removed one of our best-known and most genuinely liked medical men, and cast a shadow over the
day for all who knew him. He had been ailing more or
less for a long time, and those who knew the intensely
active nature of the man cannot feel that death would
be altogether a tragedy for one who hated inactivity,
and was never really happy unless he was up to his
eyes in work.
Dr. Turnbull had been in practice in Vancouver
for a long time, nearly thirty years—and he had practised in the East before that. Those of us who came
here before the war can remember him as a man who
did more work in a day than any other two men would
care to tackle. He had a tremendously busy office-
practice, and was to be found in his office till all hours
of the evening. He was a poor sleeper, and was late
to bed, and extremely early to rise—and the writer,
who knew and admired his energy (perhaps, too, with
a dash of envy) always had the impression that his
chief regret in life was that he could not keep office
hours between 5 a.m. and 9 a.m., when the more
serious business of the day began.
He was of the best type of general practitioner—
available to his patients at any hour of the day or
night, and keenly interested in his work. He was a
competent surgeon, too, and a good all-round man.
He was always genial and friendly, and had the complete confidence of all his patients; if he had a weakness, it was that he sometimes allowed them to impose
upon his kindness and good nature to far too great an
extent. But this is a very forgivable sin—and it is
an error that is not any too common after all. We
shall all miss "J. L." and wish for him a busy place
in whatever Heaven medical men go to when they die;
if he is not busy, it will not be Heaven for him. We
extend to his widow and family our sincerest sympathy
in their loss.
Page our own members who are able and willing to devote their time to such
work? We would not deprecate gifts to universities at all—these are most
valuable and important—but the other also deserves our consideration.
We have had instances, where excellent research work has been done, which
has redounded greatly to the credit of the man who engaged in it, and has
brought a reflected glory to Vancouver—yet it meant a considerable out-
of-pocket expense to the man himself which he could ill afford, while at the
same time financial limitations prevented him from carrying his work to
the conclusion which a little help would have enabled him to reach.
So we commend to our readers this idea, and hope they will all be so
prosperous that they will be able to put it into practice, and will live so
long that, like Dr. Nicholson, they will feel impelled to contribute before
the day comes after which they will not be able to see the good results of
their donation.
Again, our Sickness and Benevolent Fund is worthy of support, not only
by assessment, but by voluntary donation or bequest. We understand that
the British Medical Association has contributed several hundred pounds to
one of the members of our profession resident in B. C, and while of course
we cannot "keep up with the Joneses" to that extent, still we should do
what in us lies.
i
We would call the attention of all our readers to the new Vancouver
General Hospital Pharmacopoeia, now on sale at the V.G.H. for $1.2 5. The
actual cost to the hospital, we understand, is about $1.15 per copy, so that
the price is very low.
This is an unusually good hospital pharmacopoeia; in fact it is rather a
valuable little book as it contains a great deal of information which we
constantly need, but of which we can never remember where to find it.
Such things as weight equivalents, ways to make mustard poultices, quarantine tables, urine standards, various types of enemata, gastric contents
standards, how to make fruit laxatives, etc., etc.
A very valuable feature is the section on diets, giving Sippy diet, keto-
genic diets, reducing diets, and many others.
Again, the section on treatment of poisoning by various agents is the
most complete we have ever seen, and is especially valuable.
On the whole, we have never seen a more complete little volume of its
kind. The lists of pharmacopceial preparations are unusually good and
numerous. It would pay every doctor to have this volume on his desk and
use it constantly. It will do away with a good deal of proprietary advertising; and we should urge the druggist whom we usually patronise to keep
a copy too for constant reference. All dosages are given in both apothecaries' and metric systems.
Copies can be obtained by writing or telephoning the Vancouver General
Hospital, c/o Dr. Stalker, Asst. Superintendent.
NEWS AND NOTES
At the time of going to press some weddings have taken place, others
are impending and still others are rumoured. Lest this seem like a dismal
echo of "ancestral voices prophesying war," let us re-echo with immortal
Mehitabel: "Wotthehell wotthehell, tojenirs gai, cherie."
The marriage of Dr. J. Moscovitch, recently a popular member of the
m .ira
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staff of the V.G.H., to Miss Mary Armstrong, a graduate of the same hospital, took place at the home of the bride's aunt, Barclay Street, on November 30th.
Dr. W. J. McKenzie was married on December 15 th to Miss Enid
Howell.  Miss Howell is a St. Paul's graduate.
Dr. J. G. Robertson married Miss Marguerite Heisler on November 29th.
Dr. Robertson, who worked with Dr. J. G. McKay for some years and
during the past year has been associated with the Burris Clinic at Kamloops,
is taking over Dr. A. Schwarzman's practice at Tofino. The doctor and his
bride will have to acquire sea-legs of a special model, suitable not only for
navigating matrimonial seas, but for the equally hazardous navigation of
the waters of the west coast of the Island, as we understand medical practice
at Tofino is conducted chiefly in a motor-boat.
--ff'We "have "to-xongratruiate Dr.--and Mrs. Carder on the marriage of
their only daughter, Jean Margaret, to Mr. G. Bull, which took place at
Christ Church Cathedral on Saturday, December 15 th.
A baby was recently encountered in a corridor of the Medical-Dental
Building loudly proclaiming the paternity of Dr. C. H. C. Bell. We'd know
that laugh anywhere, and those eyes, those hair! As much admired as its
father by all beholders.
Dr. C. E. Brown has increased his family by twenty-five per cent, and
is very justly displaying pride in the acquisition of another son.
Dr. S. Stuart Murray, who specializes in doctoring babies, now has
another one of his own to practice on.  And it's a boy!
Dr. J. H. B. Grant was presented with a son on November 27th. He
already has a daughter, but has decided to keep them both.
We greatly regret to report the death of Dr. J. A. L. McAlpine at his
residence on the morning of December 6th at the age of 67. He had been
in poor health for some time past, and had an operation about 18 months
ago. The late doctor was one of the medical pioneers of Vancouver, being
the city's first M.H.O., and one of the original members of the Vancouver
Medical Association.
Dr. C. E. Davies left on December 2nd for New York, where he will
take a postgraduate course in E., E., N. and T.
Dr. R. D. A. Bisson, a native son of Rossland, has opened offices in the
Birks Building.
Dr. Schwarzman, the erstwhile doctor of Tofino, has swallowed the
anchor and has left via the Panama for his home in Scotland.
Dr. Bernard Myers, an eminent authority on children's diseases, of
London, England, was in the city for a few hours in the middle of November. His visit was unheralded and his stay too brief to permit arrangements
for an address to the Vancouver Medical Association.
Dr. D. F. Busteed has opened offices in the Medical-Dental Bldg., and
his numerous friends wish him all success in his new venture.
Dr. A. B. Manson, formerly with Drs. Hall in Nanaimo, has moved to
Vancouver and is now associated with Drs. B. D. and G. E. Gillies.
Dr. Neil Edward Morrison, lately an interne at the V.G.H., will commence practice at Salmo, B.C., on the first of the year. He will be associated
with Drs. Borden and McKay of Nelson.
Page 74 The vacancy created by Dr. Manson's leaving Nanaimo has been occupied by Dr. L. Giovando, formerly of Ladysmith.
British Columbia was well represented at the recent annual meeting in
Seattle of the North Pacific Surgical Association, several men going from
Vancouver and Victoria. The visiting speaker was Dr. I. S. Ravdin, Professor of Surgical Research, University of Pennsylvania.
Dr. W. J. Knox of Kelowna spent a few days in Vancouver recently, the
guest of his daughter and son-in-law, Dr. and Mrs. H. H. Boucher.
Dr. W. H. Hatfield recently returned from a three months tour abroad,
visiting the British Isles, France and Italy, where he studied anti-tuberculosis
measures as exemplified in these countries. He also brought back some good
stories, which we are contemplating issuing as a special supplement to the
Bulletin, to be mailed in a plain wrapper to paid-up members of the
Association.
Dr. J. J. Mason has returned from a brief holiday in San Diego. We
understand that he saw some golf being played there, and from being an
interested on-looker has been inspired to take up the game seriously himself.
The Library Committee has inclined its ear unto the supplication of
some of the elderly members of the Association, and is supplying sloping
book-rests on the Reading-room table, to spare them eye-strain. Will users
of the Library kindly show appreciation by refraining from burning holes
in the Reading-room tables and other furniture?
The four-year-old son of Dr. J. C. Grimson of Ladner suffered severe
fractures and internal injuries by an accidental fall from his father's car on
December 14th. We hope that his recovery will be well under way by the
time the Bulletin appears.
A binocular loupe and portable carbon-dioxide apparatus were stolen
from a doctor's car on Thursday, Dec. 20th. If an attempt is made to dispose of them to a doctor will he please report full particulars to the Bulletin office.  If they are purchased the expenses will promptly be refunded.
11
Annual Dues
Anyone who has not paid may shortly expect to see his name on the
green baize notice-board in the Library. This may be legitimate advertising,
but it doesn't help the funds of the Association.
TUMOURS OF THE BREAST
Abstract of paper read before the Vancouver Medical Association by
Dr. A. B. Schinbein, December 4th, 1934
Dr. Schinbein opened his address with an explanation. He had, some
time ago, formed a resolution that he would not again read a paper on any
subject until he had a sufficiently large series of cases of his own. However,
he had come to feel that the subject of Tumours of the Breast was so
important that it should be dealt with: bearing as it does upon all branches
of medicine, surgery, internal medicine, gynaecology and other specialties,
and pathology.
He chose, therefore, for a basis of discussion and analysis the breast
Page 71
i cases admitted to the Vancouver General Hospital in the last two years.
He acknowledged the help given by Dr. Douglas Telford, chief surgical
interne of the V. G. H.
The speaker reminded his audience of a truth too frequently overlooked,
and perhaps especially pertinent to any study of cancer: viz., that before
we can hope to understand the pathology of an organ, we must have a clear
picture in our minds of its physiology, and the natural series of changes,
both in the structure and function, that it normally undergoes. This is
especially true of the breast, which is subject to a very wide range of
physiological changes which reflect on its structure and function. There
are five main divisions, based on the chronological divisions of life, viz.:
puberty, menstruation, pregnancy, lactation, and the menopause.
. Puberty.  At this time the ducts and duct acini develop.
Ovulation (the menstrual cycle). The duct acini enlarge, new acini
form, there is hyperplasia. Secretion appears in the ducts; but these are
plugged; later involution occurs.
But during pregnancy and lactation there is again hyperplasia, abundant
and functioning, with secretion, which becomes abundant and remains for
some time.
At the menopause there is a physiological atrophy. But, and this was
the point that the speaker emphasized, all these changes are orderly, and
follow a definite and orderly course.
We may even have certain variations, which are still within normal, or
rather benign limits, and are capable of subsidence and return to normal
structure and function.  Thus we may have:
1. Excessive hyperplasia;
2. Defective absorption;
3.
4. Changes due to abnormal stimuli.
These may occur on one or several occasions.  Thus we have:
1. Premenstrual.   Large painful breast;
2. Diffuse enlargement;
3. Multiple or single areas of absorption.
Dr. Schinbein dealt next with chronic mastitis so called. This is in nearly
all cases a misnomer. We are dealing, not with an inflammation, but with
a mastoplasia: it is a most important clinical entity, and one which has led
to a vast amount of literature. It is a common cause or precursor of tumours
of the breast, and many authorities, as we shall see below, look upon it as
highly potentially malignant.
In examining these we must have a pathologist in consultation. If he
finds malignancy, we must also consult a radiologist.
Dr. Schinbein here referred to the classification by Dr. Pitts.   (Slide 1.)
(Slide 1)
Pathological Classifications
Gynecomastia (male breast).
Hypertrophy.
Hypoplasia.
Inflammations
Acute and chronic mastitis with or without abscess.
Tuberculous mastitis.
Syphilis  (only as chancre)  chiefly of nipple.
Page 76
Changes coming at abnormal times; Cystic Disiase
Single cysts.
Mastoplasia  (or chronic mastitis) with or without cyst formation.
Diffuse adenosis   (Schimmelbusch's disease).
Tumours
„ T-L       , ) pericanalicular
Benign—ribroadenoma   \ . ..    ■
( mtracanalicular
Adenoma.
Adenofibroma.
Angioma.
Lipoma.
Papilloma (duct or intracystic).
Paget's disease of nipple.
Carcinoma—simplex, scirrhous, medullary, adenocarcinoma, colloid, papillary.
Sarcoma—chiefly fibrosarcoma, myxosarcoma and adenosarcoma.
Dr. Schinbein then showed another slide dealing with the diseases of
the breast. (Slide 2.) Acute mastitis: 85% of these occur during lactation;
it may be found at puberty, and in the new-born, occasionally where there
is a pysemic condition elsewhere in the body, and as a result of tuberculous
infection. The speaker had himself had two cases, one of which had been
reported on rapid section as carcinoma, but later was found to be tuberculous. Syphilis is also a cause of mastitis and we see chancre of the breast, as
where a wet-nurse has had a syphilitic child to nurse. Sarcoma of the breast
is very rare and occurs soon after puberty. It is diagnosed by a biopsy. Dr.
Telford reviewed cases of mastoplasia and tumour of the breast of which
15 5 were admitted into the Vancouver General Hospital within the last
two years.
(Slide 2)
REVIEW OF CASES OF MASTOPLASIA AND BREAST TUMOUR
ADMITTED TO V. G. H. JULY 1932—JUNE 1934.
Clinical Classification and Incidence
Inflammations:
Acute and chronic mastitis with or without abscess.
Tuberculous mastitis.
Syphilis (only as chancre) chiefly of nipple.
Mastoplasia:
Mastoplasia without large cysts —     28
Mastoplasia with single large cyst      23
Mastoplasia with multiple large cysts      6
Total with mastoplasia    —-  57
Tumours:
Fibroadenoma    -      24
Duct   Papilloma     --      5
Lipoma               2
Carcinoma    -       67
Paget's  Disease         0
Sarcoma      --       0
Total with  tumour        98
As regards Paget's disease, while Dr. Schinbein has not himself seen a
case in his practice, this is one of the important diseases of the breast and
must be included in any classification. The age of the patient must be
taken into account in the diagnosis of tumours of the breast. Thus, we see
fibroadenoma most often in the years following puberty up to twenty-five,
whilst after this age we begin to get mastoplasia in the active functioning
breast more commonly between the ages of thirty-five and forty-five. Duct
Page 77
|Q papillomata occur most frequently before the menopause, while the peak
age for carcinoma is fifty.   Dr. Schinbein showed a chart giving the age
incidence.   (Slide 3.)
(Slide 3)
AGE INCIDENCE
< >■ O
Mastoplasia               - ..     42 26 5 5
Fibroadenoma            33 17 56
Duct   Papilloma-                                                                           54 45 69
Lipoma   __ .._   — -    44 43 45
Carcinoma           52 29 76
History and Sytnptomss There are three classical symptoms of tumour
of the breast for which we must look. First, a lump or lumps; second, pain,
and third, discharge from the nipple. Does the lump increase or vary in
size at the menstrual period or is there pain at this time? How long has
the lump been present? The examination of a patient is of extreme importance, as is the manner in which it is done. A superficial examination is the
cause of many mistakes in diagnosis. The patient should lie down on her
back uncovered to the pubis. There are three main methods of examination.
First, inspection; second, palpation, and third, transillumination. In inspecting the patient we must note the size and symmetry of the breast, any
areas of inflammation, and discharge from the nipple and signs of irritation
or excoriation, presence of pigskin, keratosis, acute carcinomatous nipple,
early signs of Paget's disease, etc.   Next look for retraction of the nipple.
Palpation. Palpate with the flat of the hand, rubbing the breast against
the underlying tissues. Both breasts must be examined. Note size of the
ducts, whether palpable as cordlike or shotty structures. Note the presence
of small cysts or lumps, whether single or multiple, solid or elastic, movable
or fixed. As a general rule it may be taken that multiple lumps are not
malignant, but this is not an invariable rule. Note where the lump is,
whether near the nipple or at some distance, whether in the duct or separate
from this. Cysts are more apt to be in the central area of the breast, while
carcinoma and mastoplasia may occur in any part. Tenderness is much more
common in mastoplasia. We must be sure and examine the gland fields,
axillary, supraclavicular, and elsewhere, the liver as to size and feel, and we
must look for skin nodules. A safe rule to follow is that all solid tumours
must be taken as malignant until proved otherwise by pathological examination.  The onus of proof is on the examiner at all times. (Slide 4.)
(Slide 4)
SYMPTOMS
Page
a
Mos.
Mastoplasia 1 1
Fibroadenoma 15
Duct   Papilloma 12
Lipoma 18
Carcinoma 15
78
74
1 1 Treatment: A slide was shown giving a summary of treatment. (Slide
5.) Dr. Schinbein referred especially to the following points. Mastoplasia
gets well or tends to do so with time, but glandular treatment is of very
great value in dealing with this form of trouble. Cutler, for instance, found
that ovarian residue cures mastoplasia. Whitehouse uses oestrus hormone
and cures a number of cases. He sometimes aspirates his cysts. A single
tumour firm and tender with sharp edges may or may not be mastoplasia,
it may be a carcinoma. We do a biopsy, and while it is safe to do this without further treatment if mastoplasia is the trouble, we must be ready to go
ahead with a radical operation if malignancy is found. A single cyst similarly should be excised and examined. If others appear we then know the
cause. The patient with scanty flow, menstrual headache and painful
breasts is ideal for ovarian residue.
(Slide 5)
TREATMENT
e a > £
e -2 .2 "3 «
■s S g „  2      -= 2 S &
H        ° :1      ig,    .§§,      o^      ? £
rv Co P    P "^    P v    u to1-1
O HW £ <       <2 < £>< cS*
7o % %      %        %        %
Mastoplasia    100 37 5 8                5
Fibroadenoma     100 73 27               0
Duct  Papilloma   100 20 60 20
Lipoma      100 5 0 50                0
Carcinoma      87 0 3 84             25              54
With regard to mastoplasia. There is a division of opinion amongst
leaders in this field. Bloodgood, Whitehouse and Boyd say that it is not a
precancerous condition, while Cheatle, Cutler and Ewing feel that it is
precancerous arid should lead to removal of the breast. Simple amputation
is sufficient if multiple cysts be found. With this division of opinion the
patient should be given the benefit of the doubt and we should make sure
of avoiding future carcinoma. An encapsulated tumour is always a benign
affair. Dr. Schinbein pointed out the importance of biopsy. As he said, it
is easy to diagnose a carcinoma where we have a hard immovable lump with
retraction of the nipple and dimpling of the skin, and the treatment is
quite obvious; but where we find a small tumour, firm and movable, with
no retraction, all such must be carefully investigated by biopsy, and again
we must be ready to proceed with radical operation if malignancy is found.
As regards results, 74% of carcinoma had local metastasis, 36c/i were
alive in three years, 22% in five years, and \%% in ten years, where operation was done rather late; but where symptoms and signs had been detected
early and adequate treatment instituted, 74' < were alive at the end of
three years, 63% at the end of five years and 44' '< at the end of ten years.
There can be no doubt that radiation pre-operatively and post-operatively
does increase our cures. Again, the cells of certain of these growths are
very radio-sensitive, and radium has a definite place in the treatment of
cancer of the breast provided it is local and there are no secondary metastasis. Anything which will destroy the tumour pre-operatively is of great
value. Some clinics use radium needles and seeds and get good results. Dr.
Schinbein showed a slide giving the progress of cases and referred to some
of the reasons why in his opinion we tend to get these cases late rather than
early.   The medical profession is frequently blamed for this but in Dr.
Page 79
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Schinbein's opinion this accusation is quite unfounded as a general rule.
Women put off going to a doctor through ignorance or fear, and frequently from economic reasons, especially at the present moment, and Dr.
Schinbein paid a tribute to the profession for the fact that the treatment
of carcinoma of the breast is definitely showing increasingly good results.
In the discussion which followed Dr. Schinbein's paper, Dr. B. J. Harrison referred to a new means of diagnosis by .v-ray on which he is working,
and which depends to some extent upon the interpretation of shadows. This,
in his opinion, may prove a very valuable adjunct to our diagnostic methods.
Dr. Prowd referred to the experiences of European clinics, especially in
Norway, where they have been getting excellent results, and where they
feel that pre-operative treatment by radiation is immensely more valuable
than post-operative.
i"
{ « f
•j
FOCAL INFECTION
Murray Baird, M.R.C.P.
By courtesy of the Osier Club, before which this paper was read.
Focal infection and its effects have been recognised in medicine since
ancient times, Hippocrates having recorded good effects from the removal
of infected teeth in certain joint maladies. While modern surgery was in
the making, long before bacteria were ever heard ofv surgeons realised that
an infected wound that produced "laudable" pus meant a localised infection
and a good prognosis. Following the tremendous strides made by the new
science of bacteriology during the 19th century, fresh interest has been
taken by the medical profession in the subject, and during the last thirty
years much old clinical information has been reinterpreted in the light of
new knowledge. Not the least important announcement during this time
was that of Poynton and Payne, who stated that they had found a diplo-
coccus in the joints and nodules in cases of rheumatic fever. To this beginning has been added the work of others, until now many authorities are
prepared to affirm that nearly all rheumatic diseases are due to streptococcal
infection. Then came the work of Rosenow, many of whose results were
propounded by Billings in his lectures on focal infection in 1916. Rosenow
related to infection in the upper respiratory tract and elsewhere, such conditions as cholecystitis, peptic ulcer, appendicitis, herpes zoster, erythema
nodosum, arthritis, endocarditis, and renal calculus. He also developed the
idea of elective localisation of organisms in certain situations. For example,
streptococci isolated from the human appendix, or from the tonsils of
patients with appendicitis, would on injection into animals produce lesions
in the appendix resembling those in the human subject. This elective localisation was soon lost on repeated culture, but could be regained by adding
the tissue involved to the culture medium. Rosenow also considered that
transmutation occurred in the streptococcus-pneumococcus group of
organisms, and was able to change one into the other by varying the technique of culture. On this basis all organisms of this group are the same
coccus with difference in morphology and in acquired characteristics.
It is self-evident in clinical medicine that different bacteria have elective
affinities for certain tissues, as is commonly seen in the case of the gonococcus
and the meningococcus. It is probably also well demonstrated by the minor
epidemics of upper respiratory infection, which have a way of producing
a large number of cases of one type at one time, so that we see the larynx
Page 80 and trachea, the lungs or the gastro-intestinal tract commonly involved in
many patients at the one time. We recognize that this is an example of
elective localisation by calling all these cases "influenza." The theoretical
basis of elective localization may be:
1. Absence of strongly anti-bacterial fluids;
2. Lack of opportunity for phagocytosis;
3. Favourable oxygen tension.
It may be said here that not all observers have been able to confirm
Rosenow's work, and many regard it as unproven. L. S. Kau, in 1933,
stated that he could find no evidence of elective localisation after injecting
filtrates and cultures of various kinds of streptococci into rabbits. The
cultures were obtained from the eye, tonsils, teeth and sinuses of 21 patients
with focal infections. He found that the filtrates, or toxins, produced about
the same effects as the fresh cultures, and that the joints and pericardium
were most commonly affected by both. He could find no particular incidence of effect on the tissues involved in the various patients.
When scientific work is inconsistent it is very hard for the clinician to
know what is the truth. It is with the object of clarifying my own ideas
on the subject that I have endeavoured to present to you some of the aspects
of focal infection which appear to me at the present time to be true.
Definition
A focus of infection may be defined as a circumscribed area of tissue
in which living pathogenic organisms are present. Focal infection, on the
contrary, does not occur until such bacteria or their toxins produce secondary effects in the body generally or in some situation more or less remote
from the original focus.
Situation of Foci
Almost any tissue in the body may become a focus of infection, but
the commonest ones are round about the upper respiratory tract, the teeth,
tonsils, accessory sinuses, adenoid tissue, mastoid and bronchi. The common
occurrence of chronic arthritis in bronchiectasis is often quoted as an
example. Other tissues which may act as foci are the skin (as for example in
furunculosis), the gall-bladder, the appendix and bowel. Arthritis is also
common in chronic ulcerative colitis and dysentery. The genito-urinary
tract may be involved, especially the prostate and vesicular seminales in
males and the Fallopian tubes in females. One focus may in turn infect
other organs and so convert them into secondary foci. The appendix is
believed to infect the gall-bladder in this way by lymphatic spread. I can
remember only one case in which I was morally certain that the appendix
was acting as a focus, and that case was so unusual in my experience that
it is quoted briefly.
A man of about thirty years of age was seen complaining of pain in the right
lower quadrant of the abdomen. He had two operation scars. His appendix had
been removed about two years before, and he had had an abscess opened and
drained about a year ago. Fie had a lump in the right iliac fossa which was
diagnosed as an abscess. Also it was noticed that he had very wheezy breathing,
in fact he had quite definite bronchial asthma. He made the statement that he
.always became wheezy as soon as he got the pain in his side. A third exploring
expedition opened into an abscess cavity and removed the tip of his appendix
which had been left behind, attached to the lower pole of the kidney. When the
patient woke up he had no asthma, and to my knowledge he had no more for
several months.
:    Mil
Manifestations
It would be futile, if not impossible, to compile a list of all the con-
Pageil II !
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ditions which clinically are, or are thought to be, due to focal infection.
Brief consideration will show that foci may manifest themselves along
several broad lines.
A. The focus may remain entirely latent and produce only local effects.
It is an admitted fact that foci can be demonstrated in large numbers
of people who are apparently enjoying excellent health, and this is a common
argument of those who partly or wholly reject the theory. As in the case
of Burdon-Sanderson and the tubercle bacillus, it is thought that a thing
so common could not be the cause of any particular consequence. It does
not follow, however, that because people do not seek medical aid they are
perfectly well. Many suffer from minor disabilities which they neglect or
ignore. Ill-health may be a very insidious growth, requiring an acute
incident to bring in the medical man, so that many people are ill who are
unaware of the fact. This applies to adults as well as children. There is a
good deal of evidence that a focus which may be carried easily when things
are going well with the individual impose a very obvious load when conditions of physical and mental strain are added. At any rate it is not
uncommon to be consulted by patients whose chief complaint is loss of
energy and a vague general malaise, and to find nothing much except possibly a slight fever and some focus of infection. Removal of foci will often
enable these patients to rebuild their energies sufficiently to carry on.
B. A focus may produce a transient or persistent bacterixmia, with all
the effects consequent thereto.
That bacteria circulate in the blood-stream of apparently healthy persons without any discoverable focus, is shown by the comparatively common
occurrence of conditions like osteomyelitis and subacute bacterial endocarditis. There are also cases of staphylococcal septicaemia which defy all
efforts to find the portal of entry of the organisms. When no focus can be
discovered it is reasonable to suppose that the bacteria have passed through
some unprotected spot, possibly in the upper respiratory mucous membrane,
without producing any visible signs or symptoms. Routine blood culture
work in large hospitals shows that bacterisemia occurs as a temporary
phenomenon in many patients who have all kinds of ailments not necessarily infective in type. Experiment has shown in the case of the maxillary
antrum that a suspension of minute particles like India ink makes its way
into the cervical lymphatics within a few minutes. This being so, it is
likely that transitory bacterixmia occurs more frequently than one would
suppose in minor upper respiratory infections such as colds, tonsillitis,
pharyngitis and the like, which produce chilly feelings and fever. Such
bursts of bacteria into the blood stream are usually mopped up by the defence
forces of the body generally. Many infections are clinically well known
to be accompanied by a bacteriatmia at their onset, as in typhoid fever,
lobar pneumonia, meningococcal meningitis. Failure of the infection to
localise is of fatal significance.
Serious and destructive invasion by pathogenic bacteria may result from
most minute and almost insignificant foci, of which post-mortem wound
infection is a good example. I once made a tentative diagnosis of typhoid
fever on a boy of 18 who was admitted to the hospital in the evening with
high fever, dry tongue, and palpable spleen. The light of morning disclosed
an acute alveolar abscess about to rupture, so that case of obscure fever
quickly recovered. I also remember very distinctly a young man who
entered hospital in the evening with a temperature of 104 and a hail-fellow-
well-met euphoria which erroneously suggested alcohol.   At post-mortem
Page 82 V >:ll 1
the next day the most significant finding was a little turbid fluid in the
sphenoidal sinus in which were large numbers of hemolytic streptococci.
We are impressed with the fact that tonsillitis may be a dangerous condition
when we see the occasional case develop a persistent septicaemia and die
after a brief illness. Persons who have foci over a long period of time
develop local and general resistance to the bacterium involved, and so are
not so liable, perhaps, to a sudden fatal dissemination of the infection as
those in whom foci develop acutely.
C. Foci may produce suppurative or ulcerative conditions elsewhere.
Suppurative conditions secondary to focal infection have been well
known to clinical medicine for hundreds of years, common examples being
suppurative arthritis, osteomyelitis, perinephric abscess following boils.
Rosenow expanded previous conceptions of this process by showing that
many cases of gastric and duodenal ulcer were in reality due to infected
emboli and so of essentially the same etiology. Any practitioner of any
experience can recall cases in which the inference of infection from a focus
was too strong to be ignored. This makes one think that in many people
who have no apparent focus one may be present nevertheless. With your
indulgence I should like to quote a few illustrative examples:
A man of 45 was seen with a complaint of swelling of the legs following
two severe haemorrhages from the duodenum. Several infected teeth had been
found and removed after the bleeding. The findings were a temperature of 99, a
systolic heart murmur, haemoglobin of 45, rapid pulse and cedema of the legs. A
diagnosis of infective endocarditis was considered, but with rest and iron the
haemoglobin returned to normal, and the patient to work. A few weeks later he
was seized with a sudden dyspncea and palpitation while at work, and was found
to be suffering from auricular fibrillation. This condition persisted until halted
by quinidine. Further scrutiny revealed the fact that the tonsils were questionable, and might easily be a focus of infection. They were removed. Apart from
one short paroxysm of fibrillation this man has remained well ever since, that is
about two years.
A young man of about 28 was admitted to hospital suffering from a perforated duodenal ulcer following a sore throat several days before. At operation
the appendix was found also to be red, swollen and acutely inflamed. The perforation and the appendicitis were both considered to be secondary to the throat
infection.
A young man of 2 5 had complained of increasing weakness, pallor and shortness of breath for two months. Examination disclosed a loud to and fro aortic
murmur, clubbed fingers, palpable spleen and slight fever. Opposite the root of
an upper premolar was a sinus from an apical abscess which had ruptured about
the time of onset of his symptoms.
Semon and Wright, in the Lancet of 1933, describe Semon's own case of
intractable boils with general symptoms. The infection was finally tracked down
to an area of infection in the alveolar margin, left behind after extraction of an
infected tooth. Removal of a piece of dead bone led to the disappearance of the
boils and restoration of normal health.
Cases such as these are rather commonplace. Chronic ulcer cases are
well known to resist treatment until foci in the mouth and throat are dealt
with. Subacute bacterial endocarditis is frequently associated with the
extraction of abscessed teeth. I have never seen focal infection blamed for
coronary thrombosis, but it is a very probable precipitating cause. It is
important in patients who have some acute inflammatory condition which
requires urgent treatment, not to forget to look elsewhere for a possible
primary source, and to urge radical treatment in order to prevent other
worse troubles or a recurrence of the old one. I should regard this as very
good preventive medicine, but it is not always easy to be sure of foci until
they have declared themselves in some way, and it is not always easy to
persuade patients of the necessity for treatment.
Page 83
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D. Foci may produce non-suppurative or so-called toxic effects.
A case was quoted above in which bronchial asthma was found in association wih appendicular abscess. Asthma belongs to the allergic group of
diseases and is probably rarely due to septic absorption. Other allergic manifestations, particularly in the skin, are not uncommon as a result of focal
infection, as in the following case:
A young man was admitted to hospital with the most intractable giant urticaria. No cause could be found until attention was directed to his nose. A
rhinologist found a frontal sinus full of pus which was evacuated with immediate
relief of symptoms.
Here is another case of somewhat different type:
A man of 43 complained of paroxysmal attacks of giddiness, so severe and
sudden that he would have to cling to any handy support until able to proceed.
A diagnosis of labyrinthitis was made. X-ray of his teeth showed seven devitalised, with two that were definitely infected. He was persuaded to have all
his avital teeth removed. His attacks ceased within a month, and he has remained
well for three months.
Iritis and irido-cyclitis are considered by most ophthalmologists to be
most frequently due to focal infection, and here the teeth, tonsils and nasal
sinuses are certainly frequently involved. Evans, an ophthalmologist, writing in the Lancet, 193 3, considers that focal infection in eye conditions
produces its effects not so much by toxic absorption, but by the agency of
rhort and long axon reflexes through the nervous system. He says that in
his experience the focus is most frequently on the same side of the body as
the eye affected, and suggests that in focal infection generally we know
very little about the part played by antidromic impulses in the autonomic
nervous system. He notes that viscero-sensory impulses can cause changes
in the skin and thinks that a good many of the phenomena ascribed to toxic
absorption could equally well be explained by an imbalance in the autonomic
system. Whatever the mechanism of production of symptoms is, the results
of treatment of the foci suggest strongly that they are the primary cause.
There is another large group of patients who have aches and pains which
originate in muscles, joints and nerves. Amongst these I place a good many
who have pain and tenderness in the upper intercostal spaces, often over the
heart, around the scapula, in the abdominal wall, often on the right side,
those with lumbago, and some of those with sacro-iliac and sciatic pain and
tenderness. Some of these people may have an early arthritis of the spine
with referred pain, others have myositis. A few of these patients turn out
to be gouty, and in some the symptoms can be relieved by avoidance of
oxalate-containing foods, but there is a large number in whom attention to
foci brings about very gratifying results, particularly if they are attended
to early. It is at times remarkable how much chronic disability can apparently be due to one devitalised tooth, and how dramatic can be the recovery
after the removal of such a tooth. In patients of this type I believe that it
never pays to leave behind any dead teeth, even though the dentist and the
radiologist agree that they can see nothing wrong with them. Probably the
most active apical infections show nothing at all on an x-ray film. It was
pointed out by Leary, of Boston, in 1919, that at least 20'/f of radio-
graphically dead teeth could be demonstrated to be infected by culture.
It has happened more than once in my experience that teeth and tonsils
which had been regarded as harmless shortly afterwards obliged by producing acute symptoms, and showing themselves up, as it were. Also it has
happened that symptoms have failed to clear up until a dead but harmless-
appearing tooth had been removed.
Page 84 —
In cases of this type, when all foci that can be found have been dealt
with to the best of our ability, and relief from pain is not secured, it is worth
while to try a bacterial vaccine like that of Warren Crowe. The fact that
such a vaccine works a remarkable cure in at least some of these cases is
not proof of their infective origin, but it does render it highly probable.
We come now to a brief consideration of the most chronic group of
diseases which modern medicine teaches are due to focal infection, namely,
the rheumatic group of diseases, rheumatic fever and the arthritides. The
most cordial disagreement exists regarding their etiology, especially that of
rheumatoid arthritis, some stating dogmatically that rheumatism in all its
forms is a focal infection, others, of whom Douthwaite of London is an
example, maintaining just as emphatically that rheumatoid arthritis is a
metabolic disease, and that infection is purely secondary and incidental.
In rheumatic fever, the accumulated evidence is favour of infection as an
important factor is very strong, but the results of removal of foci such
as the tonsils in preventing recurrences are practically negligible. The bacteriological evidence in rheumatoid arthritis is very conflicting. In 1929
Cecil, Nicholls and Stainsby announced that they had isolated a hemolytic
streptococcus from the blood and joints of over two-thirds of their patients
with chronic rheumatoid arthritis. Previously a streptococcus viridans had
been found in a few cases by several workers. Wainwright, of Johns Hopkins, gives a resume of the reports since that time, as follows:
Klugh isolated a streptococcus in 72c/c of cases, Grey and Gowen
in 58%, Wetherby and Clawson in 50%, all classified as streptococcus viridans. Dawson, Olmstead and Boots, working on blood,
synovial fluid and nodules, found streptococci in only 2.5' \ of cases,
Nye and Waxelbaum found no streptococci.
Wainwright himself, in 94 cultures by Cecil's technique, was unable to
confirm Cecil's results. He regards the presence of agglutinins in the blood
and the high percentage of positive skin reactions to streptococci found in
these patients as the strongest evidence of a streptococcal causation.
With regard to the results of treatment of foci in arthritis, Miltner and
Kuloski, of Steindler's clinic, make a report on 100 cases of rheumatoid and
100 cases of osteoarthritis. They state that in this clinic arthritis is regarded
as a focal infection, and in these 200 cases great care was taken in locating
and eradicating foci. They estimate the results as about 2 5' { better than
those in which no attention was paid to foci. In the rheumatoid cases the
results were much better in the patients under 16 years of age, also in those
adults who had had the disease under two years. No case of osteoarthritis
was cured, and only 9 were improved by the treatment. Myer Solis-Cohen
explains the poor results obtained by surgical measures alone by saying that
the foci are not really eradicated by removing teeth and tonsils, as the
organism can be grown readily from neighboring tissues. He claims that
too much stress has been laid on infected tissues, and not enough on the
infecting organism, and advocates building up the patient's resistance with
a correctly chosen vaccine.
The mechanism of focal infection in arthritis is difficult to understand,
so much so that many think there is some other factor as yet unappreciated.
It is taught that when removing foci succeeds the arthritis has been caused
by a toxic absorption. When it does not succeed, the joints are supposed to
have become actually infected and to be secondary foci. I find it a little
incredible that an organism like the streptococcus, living in and around
joints, should never produce suppuration in these cases. Besides, why should
Page 83 Hi!1
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V'.'
the experts have such difficulty in finding it even in acutely inflamed joints?
In other situations, such as pleural effusion or meningitis, it is usually not a
very difficult germ to isolate. The toxic theory is a little incredible to me
also, because I believe that people go on having arthritis after their foci are
adequately removed. Arthritis appears to me to be more analogous to
nephritis than to any other condition. Take for instance the nephritis of
scarlet fever. It arises usually between the 10th and 25 th days of the disease
at a time when it is often impossible to demonstrate any streptococci in the
throat. This resembles very much what Bradley found to be the case in
rheumatic fever, the organisms being gone from the throat when the attack
came on. The nephritis may disappear quickly, or may last for years. It is
difficult to believe that the streptococci are still causing it, say by toxic
action, long after the patient his become immune to scarlet fever. It is
possible to believe that they have initiated some change somewhere in the
body, a change which is irreversible by our present therapeutics. My own
belief is that something similar to this happens in arthritis and that until
we solve the nature of that change we will continue to have difficulty in
curing infective arthritis. Some think that the change which occurs is in
the nature of an allergic hypersensitivity of the joint tissues to streptococcal
protein, and this idea is supported by the occasional dramatic results of nonspecific protein shock with milk or T.A.B. vaccine, and by the proportion
of cases which improve on proper use of a suitable bacterial vaccine.
Conclusions
Focal infection occurs in a large number of individuals in whom it
appears to be latent and productive of no particular symptoms.
In other individuals foci may bring about a transitory or a persistent
condition of bacteriaemia, often with fatal results.
As a result of giving off infected emboli, foci may cause suppurative
lesions or ulceration at a distance, probably at sites of election of the bacterium involved.
In another group of individuals foci may produce remote effects of a
toxic or allergic nature. The rheumatic diseases probably belong in this
group, but no theory so far evolved is entirely satisfactory in all cases.
Infection probably plays a dominant part, but there may be other factors
which up to the present have not been appreciated.
WILLIAM OSLER
William Carleton Gibson
[The Bulletin takes great pleasure in publishing this address given by Mr.
Gibson before the Monro Pre-Medical Club some time ago. It gives a very fascinating account of the life of a man of whom we can never hear too much, and the
writer is to be congratulated on a labour of love.—Ed.]
"In the continual remembrance of a glorious past individuals
and nations find their noblest inspiration."—Osler.
"The iniquity of oblivion blindly scattereth her poppy, and deals
with the memory of men withmtt distinction to merit of perpetuity."—Religio Medici—Sir Thomas Browne.
William Osier, who has been referred to as "the outstanding figure of
the English-speaking medical world, and possibly of world medicine," was
born at Bond Head, Ontario, on July 12, 1849. The son of an Anglican
missionary, he was one of nine children raised in "the best of all environ-
A paper read before the Monro Pre-Medical Club, University of B. C, January, 1934.
Page 86 ments," a country parsonage. His father was a sailor of the seven seas
who took Holy Orders in the English Church and came to Canada to minister to the new settlers north of Toronto, then "Muddy York." His mother
was of Cornish descent and of an olive complexion, which fact gave rise
to many wild suggestions that she was of Indian extraction. She lived to
the age of 101 years, and continued the tradition of longevity in the Osier
family.
William was the youngest son and probably the most mischievous, history recording the fact that when very young he chopped off his small
sister's finger, was expelled from school for locking a flock of geese in the
schoolhouse, and later spent a few nights in the Toronto jail, where he was
fined one dollar for participating in what was possibly a justified "smoking
out" which the school boys had given a much disliked old school matron.
He first went to school in the town of Dundas, Ont., whither his father
moved, as he says, "in order to give my boys a better education." Here he
received his classical grounding, but little else. When he was "sent down,"
his father next sent him to Trinity College School at Weston, where he
came under his great teacher and inspirer, Father Johnson. The circular
published by the school stated that "the elder boys were to be allowed to
enter the drawing room in the evening for singing and dancing," and this
decided where the lively school boy was to go.
At Weston the young student learned of "the old humanities and the
new science," under Father Johnson. He excelled in sports and was the
head prefect of the school. Johnson was a keen student of natural history,
and knew how to interest his boys in Nature. He had a microscope with
which his boys soon learned to explore the great invisible world of Nature:
the scum on the frog pond, the diseases of plants and animals, sections of
bone, etc. Osier's training here was preparatory to entering Trinity College,
Toronto, the Divinity School of the English Church in Canada.
At Toronto he carried on his work in Divinity, but was more interested
in natural history. On entering the second year he suddenly decided to
change to Medicine, and under the influence of Dr. James Bovell, the Dean
of Medicine, who had been a frequent and enthusiastic visitor at Father
Johnson's school at Weston, he came to know the possibilities which lay
before him in medicine. He lived with Dr. Bovell, in whose library he
found the finest books anyone could desire. It was here that Osier's great
literary genius became evident and was cultivated. He "kept office" for Dr.
Bovell, and describes very vividly the of t-repeat.ed episode of Bovell getting
his desk full of bank notes and then, the next moment, giving them away
to some needy patient. Bovell was a very religious man, and ultimately
became a priest. How strange and unique that he should have influenced a
theological student to become a doctor, whilst he himself was veering round
in the opposite direction. The magnitude of Bovell's influence on Osier is
well seen in his endless scribbling on programmes, lecture notes and scraps
of paper, the name "James Bovell, M.D., M.R.C.P.," over and over again.
In order to gain access to better clinical facilities, Osier with several
friends left Toronto after two years and went to McGill. His literary
foundation had been laid in Toronto, chiefly through his intimate knowledge
of, and his great love for, "Religio Medici," the first book he bought,
and the "companion of his life's journey." At McGill he was to lay the
foundation of his great clinical experience under his staunch friend, R.
Palmer Howard, Dean of Medicine.  These three men, Johnson, Bovell and
Page 87
I
I; p
tt
u
1 1
Howard, continued to be, to the end of Osier's life, his greatest inspiration.
He dedicated his magnum opus, the "Practice of Medicine," to them.
Osier's student days at McGill were not productive of high marks, for,
then, as now, examinations were but "a plague of mind and purse," which
view Osier held till his death. His graduating thesis on pathological anatomy
was awarded a special prize for originality and excellence, both in text and
in the slides which he made and which were later presented by him to the
faculty museum. To quote his fellow student, Francis J. Shepherd, afterwards one of McGill's greatest professors of anatomy: "As a student he gave
early promise of a great future; he was always investigating and trying out
things, working independently with his microscope, an instrument which
at that time was a rarity (Dr. Bovell had given him this long-necked affair) ,
and spending much time in the wards of the General Hospital and the post
mortem room. He did not cram for examinations and took no high place
in his class.  .  .  ."
After his graduation in 1872, Osier went to Europe for two years of
post-graduate work. He studied under the great master Virchow in Berlin,
where he saw in daily use the pathological methods which he was to bring
back to America. With several English students he attended the ward
clinics in Vienna. For fifteen months he worked under Burdon-Sanderson
in London. Thirty years later he was to follow this great physiologist as
Regius Professor of Medicine at Oxford. In his London work he described
accurately for the first time the blood platelets and laid the foundation for
his later work on the blood in malaria. The writer was recently privileged
to go over some of the student note books of "the Great Physician" now in
the Osier Library at McGill and found in them every evidence of the virtue
of systematic work, which he came to recommend so earnestly to his
students. His researches on the blood served to establish the fact that certain
excitants and depressors worked on the nervous system and not on the blood
system.
Returning from England he was made lecturer in the Institute of
Medicine at McGill, a course given in pre-clinical years consisting chiefly
of physiology and histology. The following year he was made full professor
and set about his work with great energy. He put out his "shingle" but was
never "at home" for consultations. He offered himself as physician to the
smallpox ward of the Montreal General and became a member of the faculty
of the Veterinary School. His great interest in natural history continued,
and he became a member of the editorial board of the Canadian Medical and
Surgical Journal. His greatest work consisted in introducing demonstrations in pathology and in establishing the first laboratory in physiology.
He was a "practical" man, if ever there was one. He had no use for the
barren didacticism and unwholesome dogmatism which had so long charac-
terized these courses in American institutions.
The welfare of the students always received his first consideration. He
helped to found their undergraduate society in 1877. He wrote by hand
the many pages of notes which always accompanied his pathological demonstrations and ward clinics. As Registrar of the Faculty he gave them their
first and best welcome to the medical school. His introductory addresses
to the freshmen invariably mentioned two things, the virtue of systematic
work and Religio Medici. He encouraged reading for half an hour before
going to bed every night and in this way he himself came to master the best
in literature.
The Montreal General Hospital appointed him pathologist, much to the
Page 88 consternation of the older doctors, but Osier worked hard and won the
admiration of all. The careful clinical reports which he edited, the first, in
fact, that the Montreal General ever had, later formed the basis of his great
textbook. He studied disease in the wards, and followed it into the post
mortem room. His students did the same. He said: "To study the phenomena of disease without books is to sail an uncharted sea, while to study
books without patients is not to go to sea at all." With his ward clinics he
put McGill in the forefront of medical schools in America. It was his
greatest hope that he should be remembered as being the one who enabled
the student to study disease at the bedside. In this he revolutionized medical
education, a fact by which we benefit immeasurably today.
He left Montreal in 1884 to take over the chair of Clinical Medicine at
the University of Pennsylvania in Philadelphia, as he says, "a rich man,
not in worldly goods, for such I have the misfortune, or the good fortune,
lightly to esteem, but rich in the goods which neither moth or rust are able
to corrupt, friendship and good-fellowship, wider experience and fuller
knowledge."
He was a great man for playing practical jokes on people—some of
which turned out badly for him—but his frolicsome nature endeared him
to all those who really mattered. With a nature "sloping towards the sunny
side," he was ever the peace maker, the conciliator, in the many disputes
which occurred in medical bodies. At the same time he could make it
uncomfortable for "certain narrow-minded Philistines," as he called them,
who, through ignorance or vested interests, tried to hold up true progress.
Thus, when the head of the Montreal Veterinary School projected the theory
of inter-transmission of bovine and human tuberculosis, Osier was the only
one at the meeting who would have the paper published; all the other doc-
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Page 89 (!•"
i"
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H   I
ft
«'
■ii
tors were afraid of alarming the public. His interest in tuberculosis is
proverbial, and some of the finest educational work in T.B. is due to him.
McGill was stunned at the prospect of losing her famous son, and gave
him leave of absence so that he could still return if Philadelphia did not suit
him. The story of his going-away is many-sided and rather humourous.
He was in Europe when the position was offered to him by letter to his
Montreal address. Professor Shepherd forwarded the communication to
him and for a long time Osier took no action, thinking his Montreal colleagues were playing a joke on him. However, Professor Weir Mitchell of
Philadelphia was in London and decided he must find Osier at once and "look
him over." The test of a gentleman, fit to be a Pennsylvania professor, was
to see how he disposed of the stones in his cherry pie. Osier was up to the
trick, however, and did the genteel thing, put the stones in his spoon, "and
got the job"!
His classes in the University of Pennsylvania soon became popular and
he was sought after by numberless societies. His post mortems at the
Blockley Hospital were as a breath of fresh air to the teaching of pathology
at the time. His student clinics were attended by all years, and whenever
he spoke at the College of Physicians and Surgeons he was sure of a large
audience. He made friends of the men at Jefferson Medical School in the
city and did a great deal to acquaint the medical fraternity with their own
fine library. For five busy years he held the stage in Philadelphia. His
familiar ways with students were unheard of and his pranks were at first
thought to be terrible. (To be continued)
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